Book Review: Metrics: What Counts in Global Health

We live in an era of the ascendency of numbers. Forms of measurement, enumeration, and calculation increasingly constitute the basis for authoritative truth claims across a wide range of fields, from financial forecasting to the fitness of individuals and the management of populations. What to make of this phenomenon from the perspective of medical anthropology? In a cogent and timely edited volume, Vincanne Adams and her collaborators provide a critical collection of case studies to evaluate the quantitative turn in global health.

As its subtitle attests, what does and does not count plays an increasingly central role in defining and governing well-being worldwide. Adjectives like evidence-based, experimental, and cost-effective have grown increasingly indispensible in efforts to sway both public and private policy. These terms anticipate the generation of quantitative data, presented in standardized modes ready to be translated across space and time.

Such an approach permits new insights and connections, but it also risks overlooking or erasing forms of knowledge that do not fit its mold, including the specific histories, ethnographic details, and stories of experience that most anthropologists hold dear. The book’s contributors share a collective concern for the ethical and political stakes of this potential loss, particularly with regard to those whose lives are directly impacted by abstract measures. Through theoretical and empirical fieldwork, they follow examples of the new obsession with counting in practice and describing the particular collage of facts, fantasies, and oversights it has produced in different settings.

Metrics contains nine substantive chapters, divided into four parts and bookended by an introduction and an epilogue. In these two framing pieces, Adams sketches and reprises the central ambitions of the volume, while also clarifying the terms involved. Global health, she notes, differs from forerunner projects like international health and colonial health not only in terms of geographic imagination, but also in its devotion to a particular architecture of knowledge. Adams expands on this point in the first chapter, laying the theoretical groundwork for the collective project while tying quantitative reason to a deeper history of political sovereignty.

Although statistics may have long taken the pulse of the massed human populations envisioned by public health, numbers now encompass abstract artifacts of calculation and audit as much as actual bodies. The terrain for claiming truth and efficacy has profoundly shifted with the appearance of measures like the quality adjusted life year (QALY) and its many offspring (DALY, HALY, etc.); the rise of the randomized controlled trial (RCT) as the gold standard for evidence; and the heightened importance of foundations, nongovernmental organizations, and corporations relative to governments. Biomedicine is increasingly mediated by indicators, risk factors, and other amalgams of findings and estimates. These strange alloys of knowledge appear far more smooth on the surface than their inner structure would suggest. Although stories and experience still play a role in global health, they contend with a new empire of data, and its insatiable need for good numbers. As Adams herself discovered, a project might now lose funding and support if the problem it addresses displays a mortality rate too small to produce “a good power of calculation” (p. 36).

The first part of the book details this new imperative to get good numbers as it plays out on the ground. In twin studies of maternal mortality in Malawi and Nigeria, Claire Wendland and Adeola Oni-Orisan expose the deep ambiguity lurking just below the surface of official statistics. They show how such measures can fail to capture empirical reality at the level of clinical practice. Moving between macro estimates of trend lines and the messy circumstances of one 15-year-old girl’s death, Wendland methodically dismantles policy equations to reveal how they can ultimately miss precisely what they promise to reveal: the political economic conditions influencing health a given society. Oni-Orisan likewise foregrounds a particular death and the manner in which it remained unrecorded. Within a regime of constant audit, it turns out, no one wants to count things that indicate responsibility. Moreover, when numbers hold political weight, hospital records have potential effects well beyond health. In a literal form of biopolitics, a successful medical career can become the means to a political one.

Marlee Tichenor and Molly Hales expand on this political theme in the next section. Tichenor follows an effort by Senegalese health workers to mount a strike based on withholding patient data from central authorities while continuing to provide health care. Although the strike ultimately failed, it revealed deep tensions between the stark realities of insufficient infrastructure and staffing at rural clinics and the rising demands for data collection by the Ministry of Health and its international aid partners. Hales traces a similar mismatch of expectations in the context of Yup’ik behavioral health programs in Alaska. Even as the tribal government sought to assert health sovereignty by establishing a curriculum based on traditional knowledge, the data demands of granting agencies created a deep translational hurdle: how to measure “efficacy” in standardized terms for a program that emphasized a distinctly Yup’ik conception of wellness? Taken together, these two chapters highlight the long shadow of colonial inequalities and the limits of political sovereignty when asserted from positions of economic dependence.

The third part of the book addresses economic issues head on, along with the expanded scope of market reason in the wake of neoliberal policies. Susan Erikson examines how metrics can create value in the sense of future actuarial worth. Rather than simply serving as measures of retroactive accountability, numbers now also provide a mechanism to incentivize capital investments in the health and welfare of poor people. As she suggests, this overlay of financial and health interests risks shifting desired outcomes away from human well-being and toward investor profit. Lily Walkover looks at the trajectory of a small nonprofit, Hesperian Health Guides, publisher of Where There Is No Doctor. Although recognized as the most widely used primary health care book in the world, this landmark volume’s precise impact remains hard to quantify. New demands for accountability and an emphasis on evidence produced by experimental trials shortens the time frame of measurement demanded by funders, even as accounting expands into a continual chore for people at every level of health projects, from community members to donor agencies. As Walkover suggests, this ongoing struggle to render the world into a calculable place threatens to overshadow the struggle to improve basic health care that historically defined Hesperian in the first place.

The final section of the volume considers the dilemmas and relative power of stories in the face of this drive for quantification. Carolyn Smith-Morris tracks efforts at the U.S. Veterans Administration to improve quality of life for veterans suffering from spinal cord injury. As she observes, the randomized controlled trial approach risks flattening social variables such as age or profession that separate different cases relative to the job market. While ethnographic inquiry can reveal aspects of veteran experience critical to patients themselves (and to the politics of perception swirling around the VA), its results remain relatively invisible in official reporting terms such as fidelity monitoring. For his part, Pierre Minn describes the struggles of a small nonprofit, Konbit Sante, to make its efforts to strengthen the Haitian government’s health care system by supporting medical training legible to donors. Like Hesperian, the group finds itself needing to translate a moral vision of solidarity into an appropriate set of measurable performance units. While not opposed to accountability per se, it seeks to resist any demand to produce widgets that might distort its mission and enrolls the anthropologist in an effort to craft language that would explain its goals.

Taken as a whole, Metrics offers a lucid, revealing, and sometimes unnerving tour of global health’s quantitative terrain. Its authors take pains to emphasize that they are not opposed to measurement. Rather, they argue for the need to recognize the limits of numbers and the continuing significance of other forms of knowing. From the perspective of medical anthropology this is a vital book.